Global and Regional Longitudinal Strain Reduction in Breast Cancer Patients After First Chemotherapy Cycle With Fluorouracil, Adriamycin, and Cyclophosphamide Regimen

Comorbidities and cardiac symptoms can modify myocardial function regardless of ischemia: a cross-sectional study with PET/CT

Objective

Associating comorbidities and cardiac symptoms that alter myocardial mechanical function could help clinicians to correctly identify at-risk population.

Methods

We conducted a functional open population cross-sectional study of patients referred to a positron emission computed tomography/computed tomography unit in Mexico City for evaluation of myocardial function, perfusion, and coronary circulation. Ischemia was defined as a sum difference score (SDS) > 2. Association between comorbidities and cardiac symptoms was tested using logistic regression models and trend analysis. We performed an interaction analysis to evaluate the addition of any accompanying symptoms to comorbid conditions on impairment of myocardial function.

Results

One thousand two hundred and seventy-three patients were enrolled, 66.1% male, with a mean age of 62.4 (± 12.7) years, 360 (28.7%) with ischemia, 925 (72.7%) with at least one comorbidity, and 676 (53.1%) had at least one associated cardiac symptom. Patients without ischemia, type 2 diabetes, arterial hypertension, and adverse cardiac symptoms were associated with adverse function, perfusion, and coronary flow parameters. We observed a trend of a cumulative number of comorbidities and cardiac symptoms with increased ischemia and decreased coronary flow. Only in decreased LVEF, we demonstrated an interaction effect between increased comorbidities and adverse symptoms.

Conclusions

The high burden of comorbidities and symptoms in our population alter myocardial function regardless of the level of ischemia.

Echocardiographic Findings in Asymptomatic Mediastinal Lymphoma Survivors Years after Treatment Termination

Patients treated due to mediastinal lymphomas are at risk of cardiovascular complications, as they receive chemotherapy, usually containing anthracyclines, often combined with thoracic radiotherapy. The aim of this prospective study was to assess early asymptomatic cardiac dysfunction using resting and dobutamine stress echocardiography (DSE) at least 3 years after the end of mediastinal lymphoma treatment. Two groups of patients were compared: those treated with chemoradiotherapy and those exclusively treated with chemotherapy. Left ventricular contractile reserve (LVCR) during DSE was assessed using changes in LV ejection fraction (LVEF), LV global longitudinal strain (LV GLS), and a novel parameter-Force, which is the ratio of the systolic blood pressure to the LV end-systolic volume. The study included 60 patients examined at a median of 89 months after the end of treatment. Resting echocardiography showed normal LVEF of 58.9 ± 9.6%, borderline LV GLS of -17.7 ± 3%, decreased mean stroke volume (SV) of 51.4 ± 17 mL, and indexed SV of 27.3 ± 8 mL/m², and the right ventricular free wall longitudinal strain (LS) was impaired in some patients but not in all. There were no significant differences between the groups, with the exception of arterial hypertension, which was more common in the chemotherapy group (32% vs. 62.5%, p = 0.04). In resting echocardiography, only LV posterior wall LS differed significantly and was impaired in patients treated with chemotherapy (-19.1 ± 3.1% vs. -16.5 ± 5.1%, p = 0.04). DSE, performed in 21 patients after a median of 166 months from the end of cancer treatment, detected new contractility disorders in 1 patient (4.8%) and decreased LVCR in the majority of patients when determined using changes in LVEF or LV GLS, and in all patients when assessed with changes in Force. Conclusions: Most asymptomatic mediastinal lymphoma survivors showed preserved ventricular function on resting echocardiography. However, all of them showed impaired LV contractile reserve on DSE, as assessed with a simple parameter-Force. This may indicate subtle LV dysfunction and confirms the need for long-term monitoring of patients with potentially cardiotoxic cancer treatment.

Global Longitudinal Strain in Cardio-Oncology: A Review

Several therapies used in cancer treatment are potentially cardiotoxic and may cause left ventricular (LV) dysfunction and heart failure. For decades, echocardiography has been the main modality for cardiac assessment in cancer patients, and the parameter examined in the context of cardiotoxicity was the left ventricular ejection fraction (LVEF). The assessment of the global longitudinal strain (GLS) using speckle tracking echocardiography (STE) is an emerging method for detecting and quantifying subtle disturbances in the global long-axis LV systolic function. In the latest ESC guidelines on cardio-oncology, GLS is an important element in diagnosing the cardiotoxicity of oncological therapy. A relative decrease in GLS of >15% during cancer treatment is the recommended cut-off point for suspecting subclinical cardiac dysfunction. An early diagnosis of asymptomatic cardiotoxicity allows the initiation of a cardioprotective treatment and reduces the risk of interruptions or changes in the oncological treatment in the event of LVEF deterioration, which may affect survival.

Myocardial edema during chemotherapy for gynecologic malignancies: A cardiac magnetic resonance T2 mapping study

Objective

Myocardial edema is an early manifestation of chemotherapy-related myocardial injury. In this study, we used cardiac magnetic resonance (CMR) T2 mapping to assess myocardial edema and its changes during chemotherapy for gynecologic malignancies.

Methods

We enrolled 73 patients receiving chemotherapy for gynecologic malignancies, whose the latest cycle was within one month before the beginning of this study, and 41 healthy volunteers. All participants underwent CMR imaging. Of the 73 patients, 35 completed CMR follow-up after a median interval of 6 (3.3 to 9.6) months. The CMR sequences included cardiac cine, T2 mapping, and late gadolinium enhancement.

Results

Myocardial T2 was elevated in patients who were treated with chemotherapy compared with healthy volunteers [41ms (40ms to 43ms) vs. 41ms (39ms to 41ms), P = 0.030]. During follow-up, myocardial T2 rose further [40ms (39ms to 42ms) vs. 42.70 ± 2.92ms, P < 0.001]. Multivariate analysis showed that the number of chemotherapy cycles was associated with myocardial T2 elevation (β = 0.204, P = 0.029). After adjustment for other confounders, myocardial T2 elevation was independently associated with a decrease in left ventricular mass (β = −0.186; P = 0.024).

Conclusion

In patients with gynecologic malignancies, myocardial edema developed with chemotherapy cycles increase, and was associated with left ventricular mass decrease. T2 mapping allows the assessment of myocardial edema and monitoring of its change during chemotherapy.

A global case meta-analysis of three-dimensional speckle tracking for evaluating the cardiotoxicity of anthracycline chemotherapy in breast cancer

Background

Anthracycline cardiotoxicity has become one of the most common complications of anthracycline therapy. Regular follow-up of chemotherapy patients with myocardial deformation parameters might be helpful for early diagnosis of myocardial damage and protective intervention. This study aimed to investigate the value of three-dimensional speckle tracking imaging (3D-STI) in diagnosing and predicting potential cardiotoxicity in breast cancer patients undergoing anthracycline therapy through meta-analysis based on global cases collection.

Methods

Relevant case-control studies published prior to November 2021 were extracted to assess cardiotoxicity by 3D-STI in breast cancer patients undergoing chemotherapy. Weighted mean difference (WMD) and 95% confidence interval (CI) were used as pooled statistics. Meta regression and subgroup analysis were employed to identify sources of heterogeneity and publication bias was evaluated by Egger’s test and funnel plot.

Results

A total of 1,515 breast cancer patients from 14 studies were enrolled and followed up for 4 or 6 cycles of chemotherapy. Following chemotherapy, absolute values of Left ventricular ejection fraction (LVEF) WMD = –1.59, 95% CI (–1.99, –1.20); p < 0.001; global longitudinal strain (GLS) WMD = 2.19, 95% CI (1.87, 2.51); p < 0.001; global circumferential strain (GCS) WMD = 1.69, 95% CI (1.11, 2.26); p < 0.001; global radial strain (GRS) WMD = –1.72,95% CI (–2.44, –1.00); p < 0.001, and global area strain (GAS) WMD = 6.25, 95% CI (4.48, 8.02); p < 0.001 were decreased. A medium degree of heterogeneity was shown for values of LVEF (I² = 44.4%, p = 0.037) while values for GLS (I² = 59.0%, p = 0.003), GCS (I² = 81.3%, p < 0.001) and GRS (I² = 57.5%, P = 0.004) showed a large degree of heterogeneity. Egger’s test and funnel plot showed no significant publication bias in GLS, GCS and GAS data (all p > 0.05).

Conclusion

3D-STI has utility for the non-invasive and objective evaluation of changes in left ventricular function in breast cancer patients undergoing chemotherapy with anthracyclines. The current findings have clinical potential for the early evaluation of myocardial injury caused by chemotherapy toxicity.